Misdiagnosis, duration of untreated illness (DUI) and outcome in bipolar patients with psychotic symptoms: A naturalistic study
Misdiagnosis, duration of untreated illness (DUI) and outcome in bipolar patients with psychotic symptoms: A naturalistic study
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DOI：
10.1016/j.jad.2015.04.024
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发表时间：
2015-08-15
影响因子：
6.6
通讯作者：
Quarantini, Francesco Zanelli
中科院分区：
文献类型：
--
作者：
Altamura, A. Carlo;Buoli, Massimiliano;Quarantini, Francesco Zanelli
背景：许多数据显示，未治疗疾病的持续时间（DUI）对情绪障碍的预后有负面作用，但尚未对该变量对伴有精神病症状的双相情感障碍（BD）的影响进行调查。临床经验表明，许多具有精神病症状的双相情感障碍患者接受其他诊断，并经常长期使用第一代抗精神病药物治疗，其效果是缩短未治疗的精神病/未治疗的精神病症状发作（DUP）的持续时间，但不是DUI。本研究的目的是确定误诊率和DUP/DUI对伴有精神病症状的双相患者预后的影响。方法：临床资料（DUP）。通过对临床图表、伦巴第数据库的回顾性回顾，并在必要时通过对患者及其亲属的临床访谈，推断出具有精神病症状的双相门诊患者（N=240）的DUI（首次接受诊断）。结果测量包括精神和药物滥用合并症、职业状况、总体功能评估（GAF）、住院次数和自杀企图次数、抑郁/躁狂复发次数。根据DUP（1年）和DUl（8年）中位数将患者分为两组，连续变量采用方差分析（ANOVAs），二分变量采用chi(2)检验。然后以疾病持续时间作为协变量进行多变量方差分析（MANOVA）以消除该变量的影响。最后，将发病年龄、DUI、DUP作为自变量，将结果变量（住院/自杀企图、GAF评分< 50、职业状况）作为因变量，进行二元logistic回归。结果：大多数患者（61.5%）首次诊断为不同类型双相障碍，其中以妄想障碍（17.9%）诊断最多。与DUP较短的患者相比，DUP较长的患者在结果测量上没有差异。酒后驾车8年的患者住院次数较多（F=6.04, p=0.015），躁狂复发次数较多（F=5.25, p=0.023），抑郁复发次数较多（F=7.13, p=0.008）， GAF评分较低（F=17.74, p < 0.001）。方差分析后住院次数（p < 0.001）和GAF评分（p=0.003）仍然具有统计学意义。最后，二元逻辑回归显示，较长的DUl可预测GAF评分< 50 （F=1774, p < 0.001）。讨论：超过一半的有精神病症状的双相患者在第一次接触精神科服务时得到不同的诊断。DUI（但不是DUP）是双相患者精神病症状的预后预测因子。这表明早期诊断和适当使用情绪稳定剂（或具有情绪稳定作用的非典型抗精神病药物）治疗可能改善这些患者的长期预后。根据本文的自然主义设计，这些结果必须被视为初步的，并且必须通过前瞻性对照研究来证实。(C) 2015 Elsevier B.V.版权所有
Background: A number of data show the negative role of duration of untreated illness (DUI) on outcome in mood disorders, but no investigation has been carried out about the impact of this variable in bipolar disorder (BD) with psychotic symptoms. Clinical experience shows that many bipolar patients with psychotic symptoms receive other diagnoses and often are chronically treated with first generation antipsychotics, with the effect to reduce duration of untreated psychosis/untreated episode with psychotic symptoms (DUP), but not DUI. Purpose of the study was to define the rate of misdiagnosis and the impact of DUP/DUI on outcome of bipolar patients with psychotic symptoms.Method: Clinical information (DUP. DUI, first received diagnosis) about bipolar outpatients with psychotic symptoms (N=240) were extrapolated through a retrospective review of the clinical charts, Lombardy database and, if necessary, through clinical interviews with patients and their relatives. Outcome measures included psychiatric and substance abuse comorbidity, occupational status, Global Assessment of Functioning (GAF), number of hospitalizations and of suicidal attempts, number of depressive/manic recurrences. Patients were divided in two groups according to the DUP (1 year) and DUl (8 years) median, and the groups were compared through analyses of variance (ANOVAs) for continuous variables or chi(2) tests for dichotomous ones. Multivariate analysis of variance (MANOVA) with duration of illness as covariate was then performed to eliminate the effect of this variable. Finally, binary logistic regressions were performed considering age at onset, DUI, DUP as independent variables and outcome variables as dependent ones (presence of hospitalizations/suicidal attempts, GAF scores < 50, occupational status).Results: Most of patients (61.5%) received a first diagnosis different horn BD with the most frequent DSM-diagnosis being delusional disorder (17.9%). Patients with longer DUP were not different in outcome measures with respect to patients with shorter DUP. Patients with a DUI >8 years presented higher number of hospitalizations (F=6.04, p=0.015), higher number of manic recurrences (F=5.25, p=0.023), higher number of depressive recurrences (F=7.13, p=0.008) and lower GAF scores (F=17.74, p < 0.001). Statistical significance persisted for number of hospitalizations (p < 0.001) and GAF scores (p=0.003) after MANOVA. Finally binary logistic regression showed that a longer DUl was predictive of GAF scores < 50 (F=1774, p < 0.001).Discussion: More than half of bipolar patients with psychotic symptoms receive a different diagnosis at first contact with psychiatric services. DUI (but not DUP) is a predictor of outcome in bipolar patients with psychotic symptoms. This indicates that an early diagnosis and proper treatment with a mood stabilizer (or an atypical antipsychotic with mood stabilizing effects) may improve long-term outcome of these patients. In the light of the naturalistic design of the present paper, these results have to be considered as preliminary and have to be confirmed by prospective controlled studies. (C) 2015 Elsevier B.V. All rights reserved.